Warehouseman Liability Insurance Proposal
Complete a separate proposal for each location.
1. Name of Proposer (Partners or Officers, if applicable)
2. Mailing Address:
3. Location to be insured:
4. How long has current management operated this business?
5. Description of Premises:
a. What is the ground floor area?
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b. Height in stories:
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c. Total area (or cubic capacity) of premises available for storage?
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d. Identify and describe area(s), if any, occupied by tenant(s) or lessees :
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e. Any basement(s): If ‘yes’, is basement protected by automatic sump pump?
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And stored property on shelves or pallets
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f. Construction of walls?
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Construction of roof?
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g. Year built? If recently remodelled, when?
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6. Protection of Premises
a. Is location sprinklered? If ‘Yes’ describe
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(1) Wet or dry system?
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(2) Manufacturer’s name and when installed?
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(3) How often serviced? By whom?
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(4) Is system equipped with a Sprinkler Alarm?
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b. List any other private fire protection:
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c. (1) Are your premises protected by an operating Premises Alarm System?
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Central Station? Local Alarm?
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(2) Extent of Protection (1-2-22-3):
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Name of protective company:
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(3) Underwriters Laboratories Certificate No.:
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Date of expiration:
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d. (1) State number of watchmen employed exclusively by you and maintained on duty within your premises at all times when not regularly open to business:
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(2) Do they signal to a central station and how often?
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(3) How many clock stations on premises?
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(4) How many pull boxes on premises for Central Stations Signals?
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7. Are there any cold storage facilities?
8. Estimated values in storage during previous year:
Maximum: Average:
9. Give percentage (by weight) of goods or commodities stored (dry storage):
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a. Canned Foods:
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b. Other Foodstuffs:
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c. Furniture:
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d. Industrial Chemicals:
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e. Cloth Products:
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f. Paper Products:
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g. Home Appliances (other than radio or TV equipment):
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h. Radio/Television/Electronic Equipment:
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i. Liquor, wines, spirits:
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j. Tobacco Products:
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k. Tires:
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l. Other (Describe):
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10. Total number of employees?
If any employee(s) bonded, give details:
11. List annual gross receipts for each of the last five years (excluding any
cold storage operations):
Date
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Amount
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Date
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Amount
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a.
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$ Storage
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d.
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$ Storage
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$ Handling
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$ Handling
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b.
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$ Storage
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e.
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$ Storage
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$ Handling
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$ Handling
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c.
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$ Storage
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f.
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$ Storage
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$ Handling
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$ Handling
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12. What are the estimated gross receipts (excluding cold storage operations) for the next twelve months?
Storage $: Handling $:
13. Give details of all previous losses, insured or not insured, occurring during past five years, which would have been recoverable under this type of insurance:
14. Name trade associations in which membership is held:
15. Attach a complete copy of the warehouse receipt used.
16. What policy limit is desired: $
What Deductible: $
The Proposer agrees that the statements contained in this proposal are true and that, if insurance is effected, material misrepresentation or concealment of any information voids this insurance.
Insured’s Signature: Title:
Date:
Broker Signature: Date:
To be completed by agent:
Customers Goods Rates:
Agency:
Address:
This application is for the purpose of considering acceptability and premium determination and not binding on Markel International until evidence of an insurance contract has been issued by Markel International.
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